AFFIDAVIT OF LOSS
REPUBLIC OF THE PHILIPPINES)
_____________________________ ) S.S.
I, JUAN DELA CRUZ, Filipino, of legal age, residing at PUERTO PRINCESA
CITY, PALAWAN, after having been sworn in accordance with law hereby depose
and state:
1. I am a holder of a valid Driver’s License issued by the Land Transportation
Office (LTO) with License Number D11-23-004490.
2. On or about February 26, 2025, I discovered that my said Driver’s License was
lost and despite diligent efforts, I have been unable to locate it.
3. I am executing this affidavit to attest to the truth of the foregoing facts and for the
purpose of securing a replacement of my lost Driver’s License from the LTO.
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of
_______________. 20___ at _________________________.
_____________________________
(Name Over Signature of Affiant)
SUBSCRIBED AND SWORN to before me, this ____ day of
______________, 20___ in ___________________ City, with affiant exhibiting his
CTC No. _______________ ,
Issued on ______________________ at _________________________.
NOTARY PUBLIC
Until December 31, 20___
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20_______.
AFFIDAVIT OF DAMAGE TO VEHICLE FOR INSURANCE CLAIM
REPUBLIC OF THE PHILIPPINES)
_____________________________ ) S.S.
I, JUAN DELA CRUZ, of legal age, Filipino, and a resident of PUERTO PRINCESA
CITY, PALAWAN, after having been duly sworn in accordance with law, depose and
state that:
I am the registered owner of a TOYOTA VIOS with the plate number of AAA-123.
On February 26, 2025, while my vehicle was at RIZAL HIGHWAY, PUERTO
PRINCESA CITY, PALAWAN, it was involved in an accident that resulted in
damage to BROKEN WINDSHIELD, BROKEN SIDE MIRRORS, BROKEN
BUMPER.
The incident was reported to the proper authorities, and a police report was filed
under ABC-12345.
I am executing this affidavit to support my claim with GOVERNMENT SYSTEM
INSURANCE SYSTEM and for whatever legal purposes it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of
_______________. 20___ at _________________________.
_____________________________
(Name Over Signature of Affiant)
SUBSCRIBED AND SWORN to before me, this ____ day of
______________, 20___ in ___________________ City, with affiant exhibiting his
CTC No. _______________ ,
Issued on ______________________ at _________________________.
NOTARY PUBLIC
Until December 31, 20___
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20_______.
AFFIDAVIT AUTHORIZING DEDUCTION FROM SALARY FOR
FINANCIAL OBLIGATIONS
I, JUAN DELA CRUZ, of legal age, Filipino, and a resident of PUERTO PRINCESA
CITY, PALAWAN, after having been duly sworn in accordance with law, depose and
state that:
I am currently employed as an ADMINISTRATIVE AID at PROVINCIAL
GOVERNMENT OF PALAWAN with office address at FERNANDEZ ST, BGRY
TANGLAW, PUERTO PRINCESA CITY, PALAWAN.
I hereby authorize my employer to deduct the amount of SEVEN THOUSAND
PESOS (P7,000.00) from my salary every 15TH as payment for my financial
obligation to GOVERNMENT SECURITY INSURANCE SYSTEM.
I am executing this affidavit freely and voluntarily, with full knowledge of its legal
consequences.
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of
_______________. 20___ at _________________________.
_____________________________
(Name Over Signature of Affiant)
SUBSCRIBED AND SWORN to before me, this ____ day of
______________, 20___ in ___________________ City, with affiant exhibiting his
CTC No. _______________ ,
Issued on ______________________ at _________________________.
NOTARY PUBLIC
Until December 31, 20___
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20_______.
AFFIDAVIT OF ADMISSION OF PATERNITY AND USE OF FATHER'S
SURNAME
I, JUAN DELA CRUZ, of legal age, Filipino, and a resident of PUERTO PRINCESA
CITY, PALAWAN, after having been duly sworn in accordance with law, depose and
state that:
I am the biological father of PEDRO DELA CRUZ, who was born on JANUARY 1,
2024 at PUERTO PRINCESA CITY, PALAWAN to MARIA SANTOS .
I hereby freely and voluntarily acknowledge my paternity of said child.
I also consent to the use of my surname by PEDRO DELA CRUZ in accordance with
the law.
I am executing this affidavit to attest to the truth of the foregoing and for purposes of
securing the necessary registration and documentation.
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of
_______________. 20___ at _________________________.
_____________________________
(Name Over Signature of Affiant)
SUBSCRIBED AND SWORN to before me, this ____ day of
______________, 20___ in ___________________ City, with affiant exhibiting his
CTC No. _______________ ,
Issued on ______________________ at _________________________.
NOTARY PUBLIC
Until December 31, 20___
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20_______.
AFFIDAVIT OF UNDERTAKING TO SELF-DEMOLISH
I, JUAN DELA CRUZ, of legal age, Filipino, and a resident of PUERTO PRINCESA
CITY, PALAWAN, after having been duly sworn in accordance with law, depose and
state that:
I am the owner/occupant of a structure located at BRGY. TANGLAW, PUERTO
PRINCESA CITY.
I have been informed that said structure is subject to demolition due to
WIDENING/RENOVATION OF PUBLIC HIGHWAY.
I voluntarily undertake to self-demolish said structure within THREE MONTHS at
my own expense.
I am executing this affidavit as proof of my commitment to comply with the order and
for whatever legal purposes it may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of
_______________. 20___ at _________________________.
_____________________________
(Name Over Signature of Affiant)
SUBSCRIBED AND SWORN to before me, this ____ day of
______________, 20___ in ___________________ City, with affiant exhibiting his
CTC No. _______________ ,
Issued on ______________________ at _________________________.
NOTARY PUBLIC
Until December 31, 20___
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20_______.
AFFIDAVIT OF REPRESENTATION OF MINORS IN A PURCHASE OF
LOT
I, JUAN DELA CRUZ, of legal age, Filipino, and a resident of PUERTO PRINCESA
CITY, after having been duly sworn in accordance with law, depose and state that:
I am the FATHER of PEDRO DELA CRUZ.
I am legally authorized to represent said minor(s) in the purchase of a parcel of land
located at KALIKASAN HOMES, SAN PEDRO, PUERTO PRINCESA CITY,
PALAWAN.
This purchase is for the benefit and interest of the minor(s).
I am executing this affidavit to affirm my authority and for whatever legal purpose it
may serve.
IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of
_______________. 20___ at _________________________.
_____________________________
(Name Over Signature of Affiant)
SUBSCRIBED AND SWORN to before me, this ____ day of
______________, 20___ in ___________________ City, with affiant exhibiting his
CTC No. _______________ ,
Issued on ______________________ at _________________________.
NOTARY PUBLIC
Until December 31, 20___
Doc. No. : ________;
Page No. : ________;
Book No. : ________;
Series of 20_______.
SINUMPAANG SALAYSAY NG PAGBIBITAW SA PAGHABOL SA
ANUMANG PANANAGUTAN
Ako, si JUAN DELA CRUZ, nasa hustong gulang, Pilipino, at naninirahan sa
PUERTO PRINCESA CITY, PALAWAN, matapos manumpa ayon sa batas, ay
nagsasaad ng mga sumusunod:
Na kusang-loob kong isinusuko ang anumang karapatan upang habulin ang sinumang
may pananagutan kaugnay ng [Isyu o Pangyayari].
Na ako ay walang pinilit o pinwersa upang gawin ito at ito ay aking malayang
pagpapasya.
Na ako ay hindi na maghahabol ng anumang uri ng legal na pananagutan laban sa
sinumang may kaugnayan sa nasabing isyu.
SA KATUNAYAN NITO, nilagdaan ko ang sinumpaang salaysay na ito ngayong
[Petsa] sa [Lungsod], Pilipinas.
[Pangalan]
Affiant
